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There may arise a situation in which a policyholder might feel unhappy with a health insurance company due to some settlement dispute, unfair practice, or negligence. Any conflict with a health insurance company can be resolved in multiple ways starting from filing a complaint with the insurer itself. If the resolution is not satisfactory, it can be escalated to the Insurance Regulatory and Development Authority of India (IRDAI). Further escalations over an unresolved issue can be directed to the Ombudsman or taken up in a Civil Court. The step by step mechanism in which a dispute is resolved can be detailed as follows.
When a dispute occurs, it should be taken to the insurer first. The health insurance company will get in touch with the aggrieved customer over the issue. If there is an actual negligence or lapse on the company’s part, the company must be provided an opportunity to resolve the issue before it gets escalated to other channels.
All major health insurance companies in the country have their own mechanism for grievance redressal. The company’s customer service department can be contacted if there are any issues with the policy. If the issue is not resolved at the first point of contact, it can be escalated to the company’s grievance redressal office.
All major health insurance companies have a grievance redressal office that can be contacted for any major issues. Information about the contact details of this grievance redressal office can obtained in the official website of the insuresr. The following factors must be noted while filing a grievance dispute with a health insurer:
The IRDA is the governing body for insurance service providers in the country. Companies that provide life and non-life insurance service for their customers must comply with the rules and regulations set forth by the IRDA. If an issue is not resolved by the company’s grievance redressal office, filing a complaint with the IRDA against the company is the next major step in the process. The contact details of IRDA can be given as follows:
|Toll free phone number||155255 or 1800 4254 732|
|Postal address||Insurance Regulatory and Development Authority of India(IRDAI) Consumer Affairs Department- Grievance Redressal Cell. Sy.No.115/1,Financial District, Nanakramguda, Gachibowli, Hyderabad-500032|
IRDA has a repository for collecting and monitoring insurance-related grievances in the form of Integrated Grievance Management System (IGMS). This system provides centralised access to all policyholders to air and monitor their grievances whenever there is an issue. This system also plays a key role in helping policyholders register their complaints if they are not able to access the insurance company directly. The process involved in registering a complaint with the IGMS can be listed as follows:
After the registration of a complaint, a reference number will be allocated to a policyholder. This reference number can be used to access the complaint in the future.
Things to note while filing a complaint with the IGMS:
The government of India came up with the Ombudsman scheme to settle the grievances of individual policyholders out of court in a cost-effective manner. The decision taken by the Ombudsman is binding on the insurer as well as the policyholder. Insurance Ombudsman offices are located in 17 cities in different parts of the country.
Complaints for which the Ombudsman can be approached:
How to resolution process works:
This action must be taken as the absolute last resort when all other dispute resolution mechanisms have failed to resolve the issue. A case can be filed against the health insurer in the consumer court. A lawyer must be involved to plead the case in the court of law. Consumer courts have separate departments to handle issues related to insurance grievances. Once the issue is taken to court, the judgment provided by the court is fully binding on the insurer as well as the policyholder.
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